Riverton Industries

Instructions: Use the "TAB" key to move from field to field in this form. Click here to submit an Enrollment / Change Form

Declination & Wavier Form

If you have any questions, please contact
the Human Resources Department.
Email: hrmgr@rivertonindustries.com
Employer's Business Name:
 Business Telephone Number:


New Business Case New Employee
Change (complete name, SS# and any item changing)

Plan Number:

Business Address:
City, State, ZIP:
Section 1. Employee Information
Last Name:
 First Name:
 Middle Name:
Social Security Number:
 Marital Status:
-Single -Married -Widowed -Divorced
Home Address:
 City, State, ZIP, Country:
 Home Telephone:
Section 2. Coverage Declination/Waiver

To be completed if any coverage is declined or refused by an eligible employee and/or their eligible dependents:
HEALTH Plan coverage, I decline for: -Myself -Spouse Only -Children Only -Spouse & Children

Reasons for declining Health Plan Coverage: (check one)

I/We/They are covered by other group coverage Employer and Carrier Name:
I/We/They are covered by individual coverage Carrier Name:
Other (explanation required, please use the text box below to state your reasons)
Section 3. Signatures

By checking this box I hereby declare that to the best of my knowledge and belief the statements and answers to the questions on this form are complete and true. I understand that if any misstatements or omissions are made on this form, they may be the basis for later recession of the coverage. I understand that if the coverage applied for becomes effective, it will be subject to all the terms of the Group Contract. I am employed by the employer shown on this form, actively at work on a full-time basis, with a normal work week of 30 hours or more. If contributions are required, I authorize my employer to make deductions from my earnings for the cost of participating in my employer's plan.

Any person who knowingly and with intent to defraud or deceive any insurer, files a statement of claim or an application containing an false, incomplete or misleading information is guilty of a felony of the third degree.

Type Full Name: Declination Date: (MM/DD/YYYY)
To email this form, you must provide your name and email address in the fields below. If you do not receive a confirmation within 20 minutes, you probably did not enter your email address correctly.

Full Name:
Email Address:

(A confirmation is normally sent when a Declination & Wavier form is submitted.
No confirmation will be sent in this demo.)